PACCP 2017-2018 Membership and Insurance Renewal

2023-2024 PACCP Renewal Form
RENEWAL DEADLINE is May 1st, 2023 All renewals must be received, with payment, in the office prior to that date. A late fee of $30 will be charged for anything received after that point.
PACCP Member Number
Membership Category (ie. Associate Professional Counsellor)
PACCP Certification Number (if Certified)
First Name*
Last Name*
Mailing Information (not accessible to the public):
Address

Street Address

Street Address Line 2

CityProvince

Postal CodeCountry
Phone Number

Area CodePhone Number
Email (to be used for all PACCP correspondence from the national office)*
Business Address (for Find a Therapist listing; if you don't want an address listed to public viewing, please just fill in your City and Province). All member names, membership category, city and province must be listed on our Find a Therapist.

You can also access and change the information the public sees by logging in atwww.paccp.ca
Business Name
Address

Street Address

CityState / Province

Postal / Zip Code
Business Phone Number

Area CodePhone Number
Business Email
Website Address
Are you licensed by any provincial regulatory body/college such as the College of Psychologists, College of Social Workers, College of Counsellors or Mental Health Therapists, etc? If yes, please list the college and your registration number. This is very important information for PACCP to know in the event that an ethical complaint comes forward to PACCP. If you are licensed by a regulatory body, all ethical complaints much be submitted to the college for review. PACCP"s national ethics complaints committee (NECC) processes will engage upon receipt of the provincial regulatory body’s ruling and outcome determination. *
I am employed or work within a contractual relationship in counselling agency? If so, please provide the name and mailing address below.*

YesNo
If yes to above, please indicate name, address and email of counselling agency
Liability Insurance Proof (if you don't have PACCP Insurance you MUST provide proof of your own insurance)
Declaration of RenewalMust be completed in order to renew
I confirm each of the following statements:*

I have read, understand, agree to abide by and adhere to the PACCP Statement of Beliefs, PACCP Principles of Practice, PACCP Code of Ethics (2018), and all other regulations and procedures for PACCP Members.I agree to cooperate fully with the National Ethics Complaints Committee and the Ethics Complaint Procedure in the event a formal complaint is lodged against me.I have no active ethical complaints under investigation by an Association, regulatory College, legal system or entity.I have not been the subject of an ethics investigation that resulted in disciplinary sanctions (including educative, reparative, or other corrective required actions).I have not been denied membership in a professional association or registration in a regulatory college for counselling or a related field.I confirm that I do not have any other history of personal and professional conduct that conflicts with the PACCP Code of Ethics.I confirm I do not have a criminal record
Clarification on Above Statements
If you cannot confirm ALL of the above statements, please attach details to be taken into account when considering this application for renewed membership.
By renewing as a member of PACCP, I agree that PACCP is authorized to collect, utilize and disclose personal information to PACCP partner organizations solely for the purpose of communicating with me the special arrangements entered into with the PACCP, such as liability insurance plans available to members. In addition, I agree that PACCP may share personal information regarding my professional conduct, including disciplinary action, to the appropriate professional associations, regulatory bodies and/or agencies, both governmental and non-governmental, as required in order to comply with PACCP's mission of protecting the public.*

AgreeDisagree
We are looking for people to serve in a few specific roles within PACCP leadership. Please prayerfully consider if you would be willing to participate with us in these ways.
Needed Service Areas

National Board of Directors: Advocacy and Government RelationsNational Ethics Complaints CommitteeMarketing CommitteeNational Conference Planning CommitteeMB-East Branch Leadership Steering CommitteeSK Branch Leadership TeamNational Ethics Education CommitteeStandards of Practice Development TeamI do not have any interest in serving within PACCP
Signed by Member only (by signing your name to this agreement, you are stating that you have filled out the declaration and other information in honesty and integrity) - you may just type your name as a signature*
Date*

MonthDayYear
Date
How can PACCP be praying for you right now and in this coming year?
Any further comments you'd like to provide PACCP

Payment Categories

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Name

First NameLast Name
Should be Empty:

2023-2024 PACCP Renewal Form